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HomeMy WebLinkAbout0176 CLAMSHELL COVE ROAD - Health �/6 Clamshell Cow Saar. 005-031 Cotuit r i i Town of Barnstable r# Department of Regulatory Services s' BMNSrASMi Public Health Division Date I 1 0 -25 - NAB& . 166A 200 Main Street,Hyannis MA 02601 r �y. b,) Date Scheduled Time A � Fee Pd.AM l fl Soil Suitability Assessment for Sewage Disposal Performed By:_ S��PNcc� �o LLt^. Witnessed By: B XA 0 ) .JJ1V// / LOCATION& GENERAL INFORMA.T;ON Location Address Le ,� A yr�r s, ��v Owner's Name I ts-16'v / r>� L a}�-S-4 Address 11- �L�t s. �i i��L C�pJ Assessor's Map/Parcel.•��tjj Engineer's Name NEW CONSTRUCTION V REPAIR Telephone Zs� jj yo Land Use = Slopes(%) Surface Stones t�t5 Distances from: Open Water Body > 14'0 ft Possible Wet Area 0 a ft Drinking Water Well l SOU ft Drainage Way 1 'SO ft Property Line L 1 O ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes et pert tests,locate wetlands in proximity to holes) M • � is L r' Q bi 5,0,0 t S 0 �p q U J TP V15 i Parent material(geologic) CR rr% ` f- Depth to Bedrock Depth to Groundwater. Standing Water in Hole:bZ o ,a Vl VS. Weeping from Pit Face—,A" Ttat= Estimated Seasonal High Groundwater 7 '3o r r" DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: G c A s-V 4 X--- Depth Observed standing in obs.hole: in, Depth to soil mottles: In. Depth to weeping from side of obs.hole: In. Groundwater Adjustment f[ Index Well# Reading Date: Index Well level e„Y Adj.factor,,,,,-,.._.. Add.Groundwater Level,,m PERCOLATION TEST Date!— UZ Thne I t, o 0 Observation Hole# I Z Time at 9" Depth of Pere • (00 t' y/$I Time at 6" Start Pre-soak Time @ 11:0 0 11:0_0 11me(91, End Pre-soak 14 C�n�.• — �11Jd�►C3�ts� Rate MinJlnch L Z L Z. Site Suitability Assessment: tte Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back--------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:SEPTICVERCFORM.DOC DEEROBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consist Gravel) �3 Va 'f3 L S -;S-( s�L L 1k LoDSr- DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. _ s' C7-� i4 SL ioYR 3/z 1�o�aY- YtZ�ACtsL�e--i a- ze L S 7.S'Y SI (. `� �r=�-•: •a ry • ►'rz L DEEP OBSERVATION HOLE LOG Hole# 3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConslstenMGravel) o-- 8 A s V•• �oYrL 3/� �viJr �tG e.t=� • 8- z4 78 L 5 7,5--f Vh, z4-1L0 G Z.SY 4/ �� oo ft.- DEEP OBSERVATION HOLE LOG Hole# 4 Depth from Soil Horizon Soil Texture Soil Color Soil 111=110th 1 Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. ' Consistency. c,—g k St_ to-irk 3/Z, l-1Ts g—zh Flood Insurance Rate Map: / Above 500 year flood boundary No_ Yes-4 Within 500 year boundary No Yes ' Within 100 year flood boundary No Yes Death of Naturaliy Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? t� If not,what is the depth of naturally occurring pervious material? Certification I certify that on -5 a (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,experti a and experience described in 310 CMR 15.017. Signature Date Q-.\SEPM0PERCFORM.DOC Town of Barnstable P# liW— 3 ,t+t? Departmtent of Regtdatory Services 1` .,,MSTA" i Public Health Division Date it 0 _ &039 h�� 200 Main Street,Hyannis MA 02601 AM D MIMx fi A �f b& � Date Scheduled r a "Time . Fee Pd. I D D Soil Suitability Assessment for Sewa --e Disposal Performed By: S��p N c=.�1► o 1.r Witnessed By: ( � f LOCATION& GENERAL INFORMATION Location Address T �� 1 � ty� �� ��v rr. ��, . Owner's Name,� f r— �u Address Ib r✓L�t^r.5��isG,L r �l�- Assessor's Map/ParceL• tj Q�7 Engineer's Name NEW CONSTRUCTION V REPAIR Telephone# Land Use = Slopes(%) L 5'•�O 1f 'ta5f Surface Stones t�0 Distances from: Open Water Body > l 400 ft Possible Wet Area t o a ft Drinking Water Well 1 SOU ft Drainage Way '!O ft Property Lane > 1 O ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 1-4 All 5,5�0 Z,! } �v A U 0 HSI '�P3 T 9'G. 1U ' "IPZ �- I _J PS2Ix • _ -(p l N Y� Parent material(geologic) C2�'^P (` Depth to Bedrock Depth to Groundwater. Standing Water in Hole:1,�o '61_1 It. Weeping from Pit Face Estimated Seasonal High Groundwater 7 --le t DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: G oq S-1„4,%-- Depth Observed standing in obs.hole: __In, Depth to soil mottles: In. Depth to weeping from side of obs.hole: In, Groundwater Adjustment €r. Index Well# Reading Date: Index Well level Adj.factor,,,,...,.. Adj.Groundwater Level PERCOLATION TEST Date , t Z Time It, o� Observation Hole# ( Z Time at 9" Depth of Pere (0 0 �/$1 Time at 6" Start Pre-soak Time @ I'l:o v _J 1:b 71me(9"-/P �_ End Pre-soak 11:1 I 1 Z.4 t�nL �- �11Jd�►C3�ts� Rate Min./Inch G 2— Site Suitability Assessment: tte Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:I.SEPTICU'ERCFORM.DOC DEEROBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. v 1 ®- 0.4V- I tJbt ktf- R%A.%31, .a. 28 'f3 L 5 -7;s y 51(. 1` \k ll ZS- I It C- tram 5044V Lo01,1-._ DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. SL taYR 3�Z t.lo1.�Y� �rL�AatSt.e�r 8- z L S 7.ey ►3Z L SD,t*17 Z-19-Y �'�4 DEEP OBSERVATION HOLE LOG Hole# 'a Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel) o-- S A s t. • �oY It '��`G �ctiNt= �tz t,c- . 7,5'1 r�(v t~ l;"GtG trc% 7.4-mo Z-<y on fe DEEP OBSERVATION HOLE LOG Hole# 4 Depth from Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsist g-zk z -1'Lb L " e-+rt i SAW Z`> G/ Flood Insurance Rate May: / Above 500 year flood boundary No— Yes Within 500 year boundary No� Yes " Within 100 year flood boundary No--/ Yes • Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? 22 If not,what,is the depth of naturally occurring pervious material? . Certification I certify that on -5 a (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,experti a and experience described in 310 CMR 15.017. � 1z-13•o� Signature Date , Q-.WEPT1MHRCMRM.DOC Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 176 Clamshell Cove Road Property Address Gerald & Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. 7� WhenImpo filling A. General Information When filling out .` forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini a cursor-do not Name of Inspector ti use the return key. Capewide Enterprises,LLC Company Name rQ P.O.Box 763 Company Address Centerville Ma. 02632 iermn City/Town State Zip Code (508)428-4028 Telephone Number License Number ' B. CertificationAi -� I certify that I have personally inspected the sewage disposal system at this address nd that the information reported below is true, accurate and complete as of the time of the inspection. The`•i.nspection was performed based on my training and experience in the proper function and maintenance df on site, sewage disposal systems. I am a DEP approved system inspector pursuant to Sec ion 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 02/23/2007 Insp ctor's Signature-- Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 176 clamshell cove rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 176 Clamshell Cove Road 1 Property Address Gerald &Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated.below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)'in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed L176 clamshell cove rd.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 176 Clamshell Cove Road Property Address Gerald &Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ,❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 176 clamshell cove rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 176 Clamshell Cove Road Property Address Gerald &Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance.: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. f 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 176 clamshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 . Commonwealth of Massachusetts L v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 176 Clamshell Cove Road Property Address Gerald & Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. E] ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 176 clamshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 176 Clamshell Cove Road Property Address Gerald & Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of.construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 176 clamshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 176 Clamshell Cove Road Property Address Gerald &Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 ' every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 03 Number of bedrooms (actual): 03 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 02 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No ,000 :14 Water meter readings, if available (last 2 years usage (gpd)): 2002005:1 ,000 Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 176 clamshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 f Commonwealth of Massachusetts W Title-5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 176 Clamshell Cove Road Property Address Gerald &Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLc Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? measured Reason for pumping: Thick solids in tank. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1981 Were sewage odors detected when arriving at the site? ❑ Yes ® No 176 Clamshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 176 Clamshell Cove Road Property Address Gerald &Carol Antis r Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 32"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'6"X4'10"X57' Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness 0 Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? Tank pumped at inspection. 176 clamshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 176 Clamshell Cove Road Property Address Gerald &Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont j Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2-3 years.lnlet and outlet tees are in place. No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site,plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): L176.la'mshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 176 Clamshell Cove Road Property Address Gerald & Carol Antis Owner Owner's Name information is Cotuit Ma. 02635 02/23/2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date' Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping'contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert no Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is Ievel.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 176 clamshell cove rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 176 Clamshell Cove Road Property Address Gerald & Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 01-1000 gallon ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil conditions.No signs of hydraulic failure.No signs of pond ing.Vegetation appears normal.Leaching pit water to invert was 66"to pipe at time of inspection. 176 clamshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 176 Clamshell Cove Road Property Address Gerald &Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 176 clamshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 L r Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 176 Clamshell Cove Road Property Address Gerald &Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Fro n . r 176 clamshell cove rd..08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 176 Clamshell Cove Road Property Address Gerald & Carol Antis Owner Owner's Name information is required for Cotuit Ma. 02635 02/23/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: c ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Gaherty& Miller Model 12/16/94 ground water elevations.Used:USGS observation well data June 1992.Used:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 176 Clamshell cove rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 � t JUL 2 1 2 004 TOwNgj i DEP ONWEALTH OF 1VIASSACHUSETTS XECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS z w DEPARTMENT OF ENVIRONMENTAL PROTECTION W A � W ASSESSORS MAP Na e 2 /f ,o^M SVev` 0 ,J 1 PARCEL NO- TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner's Name: GERALD ANTIS Owner's Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Date of Inspection: 6/21/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally sses _ Needs Furt r valuation by the Local Approving Authority _ Fails / Inspector's Signature: Date: 6/21/04 The system inspector shall,submit opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti n. If the system.is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title.S Incnantinn Fnrm F/1 5/?()()fl 1 Page 2 of I 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy stem Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Wa. _ X Any portion of the SAS,cesspool or privy is below high.ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 Check if the following have been done.You must indicate "yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out`? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 2. Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):ter 0� Sump pump(yes or no): NO Last date of occupancy: n/a Z�SO� 3ar3V° COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1982 PER OWNER Were sewage odors detected when arriving at the site(yes or no):NO I � Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage, etc. b � ) TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction:Xconcrete_metal_fiberglass_polyethylene other( Plain)ex n/a If tank is metal list age: n/a Is age confirmed by a'Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions: L 8' 6"H 5' 7" W 4' 10"" Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 8" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 7 Page 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order.(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a R Page 9ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) 9 ) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD T OF LIQUID IN IT AT TIME OF INSPECTION.STAIN LINES INDICATE THE PIT HAS 6" OF EFFECTIVE LEACHING LEFT.BOTTOM IS AT 9 FT.PIPE COMES IN 2' LOWER THAN N CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) J Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): n/a Q Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. tlJ 00, A G AV OA P),O , � VD Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 176 CLAMSHELL COVE ROAD COTUIT,MA 02635 Owner: GERALD ANTIS Date of Inspection: 6/21/04 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: . NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER-12+FT. 11 Fes$..... .. .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....................OF....................................................................................S17BJECT TO APPROVAL OF N_! TABL CINSERVATION Applirafion for 11ispos al Works Tonstrnrtion rr�t��r-3.0 N c� d Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal \9� System at Z� C -�:: ;� ........................................ `7------------------------ s 9 Location• 04ress P No. ,f� ..K:j........... W Owner Address :_........., ??r � ......................................•----................---•--•--------...---•--••-----•--• Installer Address Type of Building Size Lot...2. G ®.....Sq. feet U Dwelling—No. of Bedrooms.........3..............................Expansion Attic ( ) Garbage Grinder Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixt es ..•-••-••--••-----•---•--------- . W Design Flow..............., _._..................__.gallons per person per day. Total daily flow...........�-7-_•--..................gallons. WSeptic Tank—Liquid'capacity./!�tg.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width a.............._.... Total Length............ .......Total leaching area....................sq. ft. Seepage Pit No..../-------------_ Diameter./e?,. ........... Depth below inlet.._............. Total leaching area.��.......sq. ft. Z Other Distribution box ( ) Dosin tank ( �S '-' Percolation Test Results Performed b � �.. . _. Date.._.. �(� .. y =� Test Pit No. l._G�-....minutes per inch Depth of Test Pit-----Z ...... Depth to ground w ter......!v.6._&!r (s, Test Pit No. 2.....4.-?a _minutes per inch Depth of Test Pit.....�2 Depth to ground water.._.ly.e�rlt�... �+ --•---------•-------•-----••-•------•-•-•--••••-------------------------------------------------•---...........................1_........................... . O Description of Soil....................Q- -----L.......... Y.f............... .. x W •---------------------------------------- ------------------------------------------•---------•-----------------------------------••---------------------------------------- -------------- x ••-----•--------------------------•----•------------------------------•-----••-----------------------...------...eI ------------------------------------•------------------------- ------. U Nature of Repairs or Alterations—Answer when applicable..........,/ Q_-40__A,/...........IAj._ ............... ----•---------------••---------••---•------------------------------------------•••-•-•----•--•-----------•--------------------------...---._....-----------------------------------•----•-------•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary yissdby The.undersigned furth agrees not to place the system in operation until a Certificate of Compliance has bee the b rd ed.... ... ...............:....... ............................ Application Approved By---- - `1 �..... / ' ........................ ....-_��,� , 1--------- Date Application Disapproved for the following reasons:---------•--•---------------------•---------•---•---•---------•--•-------•-••--•---------------------........... .................•--•------................--------------.....-----------.........------.......--•---------.....------.........---•-----•--••--------•--------•---------••-------•------•---•--.....----- Date Permit No......................................................... Issued-.................................... ................... Date No .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH fi ...........................................OF............................. �ftratiow for Dwvosal Work, i T ontitrurtion ramit -Application is hereby madefor a Permit to Construct or Repair an Individual Sewage Disposal System at: I eor 51 -P'T. a.... ...... _V7........................................................................... ca 4V Address Lo NO._S....................... ... .......... ..... -r-1------------------------------ ........aew-r t't " 0 Address ....... ...............................................ly ............................ Address 7 a&V 49 Type of Building Size Lot________✓................sq. feet Dwelling—No. of Bedrooms........... -------------_--------------Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Pr Other fi S ...............................•..........................I........................................ 3US --------3-xcr----------------------------- Design Flow..................................pvgallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity...........gallons Length________________ Width___.__.________. Diameter--.---__________ Depth____________._.. Disposal Trench No ---------I— 't....... WiCU .................. Total Length........el..-* 9..... Total leaching area....;too......sq. ft. Seepage Pit No.—/_ I ---- ------------- Diameter._________._..._.._. Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosin&rtank ' "'7 1 '9P /f TY Percolation Test Rest�tsk Performed by. ....e- 49...... , ......... ...... .......lt7.�l..................... Date______. Test Pit No. 1....&L......minutes per inch Depth of Test Pit.......14......... Depth to ground water__-________------------ A.0 o ov 4Q' Test Pit No. 2................minutes per inch Depth of Test Pit._._________.___._.. Depth to ground water........................ P4 ........ Descrip tion of Soil . ...... ..... ... ............... 0 t-V-s------------ ................................................................................................................... ..... ..................................................... -----------------------*----------*-----------------------------­------------------------------------------11�---------*------------------------------------------------------------------- .................................................................................................................... _0.iv. ............z�...A-7-e-k----------------- U Nature of Repairs or Alterations—Answer when applicable---- .......................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T T-Zj 5 of the State Sanitary Code he under r e not to place the system in . e" operation until a Certificate of Compliance has been ois e by th I Vard�- eaI 0?ig ed ------------ ----------------------------- ---- ......... - ------------------------ Application Approved By...... 1...................... .......... .............. .......................... Date Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued_...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF' EAL ..........................................OF..................................................................................... Tntifiratr of Toutpliaurr TH�I TO CEPePtX l theIndividual Sewage Disposal System constructed or Repaired by.... .............. .............................................................................................. W ...... ---------- A it at..................................................................................................................................................................................................... has been instilled in accordance with the provisions of TEl Whe State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated._..._....._._________._.___...____.__..___-___. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ........... ......................... nsp ............................................... ......... ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 5--4-1EALTH ...........................................OF.................................................................................... .............. FEE........................ E orko j�eiitnrtivtt Vamit hsvosa�A Permissioq-*hereby granted........ .....ev.... ................................................................................................................... to Constr9c �e�p ( g ,�ividaal.Sewage kiv sal M�t t_;�d or atNo.--------- ............................................................................................................................................................................... Street as shown on the application for Disposal Works Constructio-p-P-el'gift O.i� ed.......................................... .14.... D4 .......................................... ......................................... DATE..................... foa�d of Health .......................................... FORM 12$5 HOBBS & WARREN. INC.. PUBLISHERS G-a i 5 5' 9"l -� 2 11 \ f LOCATION SEWAGE PERMIT NO. f 176 C 619NS114G G C© ✓el?® -C67"1 i VI L L A G £ (S ,t a c� 'y T,+ wof tz I III STA LL/ER'S WA'ME & ADDRESS - ,Y/v.T/S t 0 I'L D E R OR OWNER DATE PERMIT ISSUED DAT E. COMPLIANCE ISSUED ��.._ ��1 �c 1 � � c� �, s- ,� � �� � �� --- ,; �- NOT TO• SCF,7L E , T TOR FON. F/N/SN G�Pi40E ' • ' '� f: o,! , '' SEq T/G' T.9N.t' !y t30X _ F/N/ 0` '0 ills T/iyt Y/; // /�7� C;/P/QOE OVER /,2 M/N COVER i/i:y/l�//+a/i%/ii /i/F/1ir-is� lilt/ice r� //�E/ii�//r •/�i�/i /i/:///e/r��!is/iir r od• o.; Al? .�R/C.1r �. MO/PTq,P TO oy� CO�/CRETE CO✓ER ` ��: /2 �ELO/V 4.P.gOE M/N iVT /OD LBS. 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